[Congressional Record Volume 155, Number 148 (Wednesday, October 14, 2009)]
[Extensions of Remarks]
[Pages E2522-E2524]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




      COMMENDING THE STAFF AT JOHNS HOPKINS BAYVIEW MEDICAL CENTER

                                 ______
                                 

                         HON. JOHN P. SARBANES

                              of maryland

                    in the house of representatives

                      Wednesday, October 14, 2009

  Mr. SARBANES. Madam Speaker, as Congress works to extend health 
insurance coverage and improve the quality of care for all Americans, I 
would like to commend the Johns Hopkins Center for Innovative Medicine 
and their Aliki Initiative, an effort to restructure medical education 
with an emphasis on patient-centered care, for creating an innovative 
program that puts patients first. The Center for Innovative Medicine, 
launched five years ago by Dr. David Hellmann and Mr. Richard Paisner, 
has three goals: getting doctors to know their patients as people, 
members of families and communities; encouraging collaboration among 
all members of the Johns Hopkins Bayview campus; and creating a culture 
where everyone on the Bayview campus feels like a part of something 
special.
  The Center's Aliki Initiative focuses on the first goal and has been 
called the most important innovation in graduate medical education in a 
generation by the renowned historian Dr. Kenneth Ludmerer. As described 
in Pharos, the journal of Alpha Omega Alpha, the honor society of 
medical schools, the Aliki Initiative seeks to train young doctors to 
get to know their patients as people. Through the generosity of Mrs. 
Aliki Perroti, internal medicine residents care for patients 
hospitalized at Johns Hopkins Bayview Medical Center under the 
direction of Dr. Roy Ziegelstein and Dr. Cynthia Rand. This initiative 
emphasizes that optimal medical care can only be delivered if medical 
treatments are tailored to the individual patient, and this can only be 
done if doctors get to know patients better as people, which sometimes 
involves visiting them at home after hospital discharge. Dr. Charles B. 
Green, Surgeon General of the Air Force, circulated the Pharos article 
to all Air Force Medical Service personnel and said, ``It [the article] 
emphasizes the necessity for all of us to understand that health care 
must be patient-centric. We must know our patients and ensure schedules 
provide time for care teams to spend with patients. We must focus on 
the patients to help them achieve new levels of health.''
  Madam Speaker, I commend the hardworking people at Johns Hopkins 
Bayview Medical Center, the Center for Innovative Medicine and the 
Center's Aliki Initiative. Their work should be seen as a model for 
improving the quality of care for all Americans. I'd like to enter the 
full text of the Pharos article into the Record.

        Teaching Residents to Know Their Patients as Individuals


      the aliki initiative at johns hopkins bayview medical center

       Neda Ratanawongsa, MD, MPH; Cynthia S. Rand, PhD; Cathleen 
     F. Magill, MD, MHS; Jennifer Hayashi, MD; Lynsey Brandt, MD; 
     Colleen Christmas, MD; Janet D. Record, MD; Eric E. Howell, 
     MD; Molly A. Federowicz, MA; David B. Hellmann, MD; Roy C. 
     Ziegelstein, MD


                          Ms. P: Case summary

       Ms. P is a fifty-year-old woman with a history of 
     hypertension who presented to the hospital with a severe 
     allergic reaction to over-the-counter pain medications. 
     During her hospitalization, Ms. P admitted to the intern that 
     she had experienced the same allergic reaction before and 
     felt ashamed that it had occurred again. In discussing how 
     Ms. P organizes her medications, she also admitted that she 
     only intermittently takes her blood pressure medications. She 
     revealed that she is a busy caregiver for her mother and son, 
     both of whom live with Ms. P and have complex medical 
     problems of their own. The intern, consulting with her 
     resident and attending, wondered how she can best help

[[Page E2523]]

     Ms. P return home safely and avoid future problems with her 
     medications.
       Sir William Osler, if reincarnated and the attending for 
     Ms. P, would have taken this opportunity to teach his 
     residents the importance of knowing her as a person, for it 
     was he who famously observed, ``It is much more important to 
     know what sort of a patient has a disease than what sort of 
     a disease a patient has.'' Despite increasing evidence 
     that knowing the patient as an individual improves patient 
     outcomes, graduate medical education (GME) pays little 
     attention to affording residents the opportunity to know 
     their patients well.
       If you ask the members of an inpatient ward team what keeps 
     them from knowing their patients, most--from students to 
     residents to attendings--say, ``We don't have enough time.'' 
     Medical historian Kenneth Ludmerer laments the recent focus 
     of residency training on service over education, with 
     residents caring for greater numbers of patients for shorter 
     periods of time. He argues that a fundamental educational 
     principle of traditional medical education requires that 
     residents learn deeply from and about fewer patients, citing 
     the landmark report by Abraham Flexner: ``Men become educated 
     by steeping themselves thoroughly in a few subjects, not by 
     nibbling at many.''
       Hippocrates wrote, ``Healing is a matter of time, but it is 
     sometimes also a matter of opportunity.'' At Johns Hopkins 
     Bayview Medical Center, we are seizing the opportunity to 
     give residents the gift of time to allow them to become 
     healers and know their patients in the way Osler recommended. 
     The Aliki Initiative--a new educational program named for 
     philanthropist Mrs. Aliki Perroti, who supports our efforts--
     reduces residents' workloads and creates new opportunities 
     for residents to know their patients more fully both inside 
     and outside the hospital. The program provides residents the 
     time both to get to know their patients and to learn from the 
     reflect with their teachers.


                 the importance of patients' narratives

       The opportunity to know patients as individuals is one of 
     the greatest rewards in medicine. The narratives of our 
     patients' lives fuel our passion for this work and keep us 
     grounded in the art and humanity of medicine. By allowing us 
     into their lives--whether through a single, brief interaction 
     in the hospital or an enduring relationship over decades--
     patients bestow on us a special privilege.
       Beyond this, however, our capacity to know patients as 
     individuals allows us to translate the best evidence-based 
     medicine into the highest quality, personalized care. In 
     1977, George Engel exhorted physicians to break free from the 
     constraints of the biomedical model to understand ``the 
     patient as well as the illness'' by uncovering the 
     psychological and social aspects of patients' lives and life 
     views. This patient-centered framework of care is associated 
     with improved patient outcomes, including better quality of 
     life, improved adherence, pain reduction, and improved blood 
     pressure control.
       Despite its demonstrated benefits, the widespread failure 
     of the health care system to provide individualized, patient-
     centered care is directly linked to suboptimal patient 
     outcomes. A survey of 39,090 patients by Consumer Reports 
     published in 2007 shows that fifty-eight percent of them feel 
     their doctors do not know them as individuals. Another report 
     in zoos indicates that, on discharge from the hospital, fewer 
     than half of patients can list or explain the purposes and 
     side effects of their medications. A study by D. R. Calkins 
     and colleagues published in 1997 shows that physicians, on 
     the other hand, tend to overestimate the quality of their 
     discharge instructions. A 2007 paper by Derjung Tarn and 
     coworkers noted that physicians prescribing new medications 
     only stated the name of the medication seventy-four percent 
     of the time and addressed adverse effects and duration of 
     therapy about one-third of the time. This failure by 
     physicians to communicate critical elements of medication use 
     may contribute to failure by patients to take medications as 
     directed. Similarly, Sunil Kripalani and colleagues in an 
     article published in 2007 report that communication between 
     hospital physicians and primary care physicians is often 
     lacking or suboptimal in detail, affecting the quality of 
     care in twenty-five percent of follow-up visits.


Patient centeredness--one of six core aims for improving the quality of 
                    health care in the United States

       The Institute of Medicine (IOM) report Crossing the Quality 
     Chasm highlights patient-centeredness as one of the six core 
     aims for improving the U.S. health care system. The report 
     defines patient-centeredness as: ``Providing care that is 
     respectful of and responsive to individual patient 
     preferences, needs, and values, and ensuring that patient 
     values guide all clinical decisions.'' Toward that goal, the 
     IOM in the follow-up report Health Professions Education: A 
     Bridge to Quality proposes that skills in providing patient-
     centered care should be a central competency for health 
     professionals.
       Unfortunately, traditional GME is not prepared for this 
     imperative. The goal of GME is not only to provide trainees 
     with the knowledge and skills to care for patients like Ms. 
     P, but also to inculcate in them the core values of the 
     medical profession. GME today, however, is largely driven by 
     the service needs of medical centers instead of thoughtful 
     educational priorities. Residency graduates emerge from three 
     years of stressful, demanding training ill-equipped to 
     provide the type of patient-centered, quality care Ms. P 
     deserves. Rather than learning to care for patients 
     collaboratively across transitions and in the greater context 
     of their lives, health care is both practiced and taught in 
     ``silos.'' At the same time, the structure and financing of 
     GME elevates the business of medicine over the vocation of 
     medicine, creating a hidden curriculum in which ``the values 
     of the profession are becoming increasingly difficult for 
     learners to discern.''
       Medical school curricula at many schools show an increased 
     emphasis on patient-centered care and the value of effective 
     patient-provider communication. However, once these 
     physicians-in-training enter the typical residency program, 
     they find that their training experiences do not reinforce 
     this emphasis and are not structured to allow them to know 
     and understand their patients as individuals. Unlike 
     proficiency in traditional medical knowledge or clinical 
     judgment, the skill of knowing one's patient as an individual 
     may decline under the influence of a hidden curriculum that 
     may not promote humanistic care. Duty hour reforms limiting 
     the number of hours without adjusting the volume of work may 
     lead some residents to make conscious decisions about how to 
     spend their time, as voiced by one resident in a 2005 survey: 
     ``It is harder to have as much time to speak with and really 
     get to know patients, which impacts the ability to have 
     shared decisions and understand patient perspectives.''
       Finally, GME leaves little time for reflective learning. 
     Reflection allows physicians-in-training to think about the 
     meaning of their experiences with patients and how these 
     experiences are influencing their own overall professional 
     development. Although medical educators promote the potential 
     value of self-reflection through activities like 
     critical incident reports and portfolios, trainees' 
     capacity for reflection may decline with the workload and 
     fatigue of residency training.
       Thus today's young physicians-in-training may master the 
     mechanics of delivering medical care, yet never have the 
     opportunity to learn the art of healing.


  Creative philanthropy--key to success of the Rockefeller Foundation

       At the turn of the twentieth century, Frederick T. Gates 
     advised John D. Rockefeller to establish an institute of 
     medical research focused on medical education reform. 
     Rockefeller's $32 million endowment of the General Education 
     Board comprised the largest gift to higher education up to 
     that time. In 1905, Henry Pritchett of the Carnegie 
     Foundation commissioned Abraham Flexner to study the state of 
     medical education in North America and to make 
     recommendations to improve it. This effort resulted in the 
     publication of the Flexner Report, perhaps the most 
     influential document in the history of American medical 
     education. These achievements a century ago represent 
     striking examples of the ways creative philanthropy can both 
     reform and shape medical education to meet the needs of 
     society.
       The need for educational reform is once again upon us, but 
     the funding constraints of a market-driven health care 
     environment hamper innovation by hospitals and educators. 
     Reform in the twenty-first century may require educators to 
     consider again the potential of partnering with the public. 
     The Aliki Initiative is a program designed to create 
     physicians who treat all patients with compassionate, 
     competent, and personalized care.
       The Aliki Initiative aims to develop caring doctors who 
     have a genuine and deep appreciation of the importance of 
     knowing each patient's unique personal circumstances and who 
     make patient care recommendations that apply the best 
     evidence to the individual patient. The program reduces the 
     number of patients assigned to each resident, providing 
     residents more time to spend with patients during and after 
     their hospitalizations, and thus offering new opportunities 
     for residents to learn from and about their patients.
       The Johns Hopkins Bayview Medical Center is an academic 
     medical center serving 8700 medicine inpatients per year; 
     twenty percent are poor. Patients hospitalized on the medical 
     service receive care either from a hospitalist service or 
     from one of four house staff teams. Teams contain one 
     resident, two interns, two students on basic medicine 
     clerkship rotation, a faculty attending, and a case manager. 
     A traditional team admits ten patients every fourth night on 
     ``long-call'' and four patients during an intervening 
     ``short-call.'' In October 2007, one team became an Aliki 
     Team, admitting five long-call patients and two short-call 
     patients. Hospitalists care for the patients who would 
     otherwise be admitted by this house staff team.


       Lower patient load enables more teaching to the Aliki Team

       With this reduced census, the Aliki Team has the time to 
     participate in teaching sessions and mentored experiences 
     designed to foster appreciation of knowing each patient as a 
     unique person and understanding each patient's psychosocial 
     circumstances. This begins from the admission encounter, when 
     house staff learn to elicit a more meaningful, detailed 
     history that includes patients' understanding of their 
     illness and their health. By engaging in this dialogue with 
     patients, their caregivers, and their outpatient

[[Page E2524]]

     health care providers, house staff learn who and what 
     patients have left behind when they arrive at the hospital, 
     an often forgotten but equally important transition time.
       Residents also learn how to provide counseling and 
     treatment to match patients' needs and concerns. One key 
     component of the Aliki Initiative is learning to assess and 
     overcome potential barriers to medication adherence, 
     particularly by tailoring evidence-based treatment to the 
     patients' particular preferences and resources.
       During each day of the hospitalization, house staff 
     continue these conversations, honing their skills in patient 
     education and joining with patients in shared decision making 
     about diagnostic or therapeutic options. Leading up to and on 
     the day of discharge, house staff prepare patients and their 
     caregivers for the transition to home, rehabilitation 
     centers, or other settings in the patients' communities.
       In contrast to usual practice following discharge, 
     residents call all patients within a few days of discharge to 
     answer questions, check their understanding of the 
     hospitalization and treatment recommendations, review their 
     understanding and ability to adhere to the discharge 
     treatment regimen, and offer assistance with any problems 
     that have arisen in the transition.
       Finally, the Aliki Initiative provides the most powerful 
     learning opportunity of all: team members learn to know their 
     patients as individuals within their own homes and 
     communities. Five or more patients per month give residents 
     permission to visit them after discharge in their homes or 
     subacute care facilities. Often, patients allow residents to 
     photograph or film these visits, so the house staff can teach 
     their colleagues about these rich, rewarding experiences 
     during a monthly Aliki morning report conference.


         Outcome--narrative medicine yields better patient care

       Since October 2007, over half of our house staff have 
     participated in the Aliki rotation. During hospitalizations, 
     residents spend more time at the bedside with their patients 
     and patients' loved ones, discussing medications and other 
     treatments and coordinating care with outpatient providers. 
     Interns and residents say they gain their greatest insights 
     during their time with patients after discharge, when they 
     call all of their patients and visit five or six patients at 
     their homes or subacute care facilities.
       In addition to enhanced time with patients, team members 
     have the time to reflect on their professional and personal 
     growth, both individually and as a team. Each month, faculty 
     and attendings working with the Aliki house staff meet to 
     debrief the team about their experiences. The most striking 
     and consistent observation is how often house staff report 
     ``being surprised'' by what they have learned about their 
     patients. Prior assumptions about a patient's preferences, 
     barriers, abilities, or concerns are regularly challenged 
     when residents take the time to know patients individually. 
     This deeper insight, in turn, has repeatedly led to 
     opportunities to provide better patient care. Below we 
     present some examples of ``assumption-challenging'' Aliki 
     experiences and how they impacted patients and house staff.


                         Ms. P: The Home Visit

       A few days after discharge from the hospital, the Aliki 
     Team intern and attending visited Ms. P at her home, learning 
     more about her home situation and meeting her mother and son. 
     They discovered that--in an attempt to remind herself to take 
     her medications--Ms. P keeps her medications on her dining 
     room table. Otherwise, she reported, the medications are 
     ``out of sight, out of mind:' The intern realized that both 
     Ms. P's mother and her son also keep their prescription and 
     over-the-counter medications in the same location, increasing 
     the chances that any of them could take the wrong medication. 
     The intern also learned about the ways Ms. P copes with 
     caring for her family, including the supports she receives 
     from her community. Together, the intern and Ms. P 
     brainstormed about how to organize her medications more 
     safely and help her remember how to take them.
       From the home visit the intern learned more about the 
     challenges of integrating a complex medical regimen into a 
     person's daily life and ways to engage patients in finding 
     solutions to these challenges. Ms. P expressed appreciation 
     that the intern took the time to come to her home: ``They 
     treated me like I was someone special.''
       This learning experience is just one of many. Other 
     examples of Aliki experiences include:
       An intern spent significant time with a man facing a 
     difficult decision about treatment for pancreatic cancer. The 
     patient initially told him, ``I'll do whatever you say, 
     Doc.'' Nevertheless, the intern patiently spoke with him 
     every day to learn about his goals of care and preferences. 
     He wasn't sure he was making any difference until one day the 
     patient told him, ``Doc, I don't want any of those things. I 
     want to go home.'' The intern helped him transition to home 
     hospice, and felt certain that this was ``the right thing to 
     do for him.''
       A former Aliki resident working as the urgent care doctor 
     for the clinic described ``an Aliki moment'' during which he 
     discovered that a patient with gastrointestinal bleeding was 
     unable to afford his proton pump inhibitor after 
     hospitalization. Experience on an Aliki Team gave him the 
     skill and confidence to ask the patient explicitly and 
     thoughtfully about all barriers to adherence. The resident 
     switched the patient to a generic medication covered by the 
     patient's insurance and spent time counseling the patient 
     about the rationale for this therapy.
       An intern visited a patient with urinary retention in a 
     subacute care facility and learned that the patient's Foley 
     catheter had been removed despite notations not to do so in 
     the ``hospital course'' section of the discharge summary, and 
     despite the patient's own recall of their recommendations. 
     The team resolved that in the future they would document more 
     explicit instructions with the medications list at the end of 
     discharge summaries and call ahead to subacute care 
     facilities for similar important follow-up issues.
       Although residents were initially concerned that fewer 
     patients would mean less opportunity for traditional medical 
     learning, in fact, they report having more time for evidence-
     based and bedside teaching. One team decided to focus on 
     physical diagnosis skills. The teaching attending physician 
     on this team described the experience as ``the first time I 
     am sure that the interns really knew how to examine a patient 
     by the end of my weeks with them.'' The supervising residents 
     also relished the additional time to search the literature 
     for articles and prepare teaching for the team.
       House staff participating in the Aliki team feel greater 
     pride and more fulfilled in their work. In the words of one 
     intern, ``It's given me time to be the kind of doctor I've 
     always wanted to be and do the things I should be doing for 
     all my patients.''


                            Ms. P: Epilogue

       Asked about the home visit, Ms. P said, ``I thought those 
     days were over. You know, how the doctors used to come to 
     your house. They came down, sat down to talk, to see how I 
     was getting out of the hospitalization. And that made me feel 
     good because some doctors don't have that interest or do a 
     follow-up to find out how the patients are doing . . . That's 
     letting the patients know that someone else cares. That made 
     me feel that I was important, and they're learning from me! . 
     . . They treated me like I was the only patient they had to 
     see that day. They treated me like I was someone special.''


      Where from here? More opportunities for innovative medicine

       Our early experience suggests that the Aliki Initiative has 
     the potential to increase residents' skills and motivation to 
     deliver patient-centered care. Ongoing and planned 
     evaluations of the program's outcomes include:
       An assessment of Aliki residents' self-assessed behaviors, 
     attitudes, and skills before and after participation in the 
     experience.
       Trainees' perceptions and understanding of medication 
     adherence and cost.
       An audit of the medical records of patients cared for by an 
     Aliki team, compared with patients cared for in other 
     settings, to evaluate prespecified aspects of inpatient care, 
     transitions of care, and the quality of discharge 
     documentation.
       In addition, we will examine the impact of the Aliki 
     Initiative on such patient outcomes as hospital length of 
     stay, quality and safety of the transition from hospital to 
     home or to another care team at a skilled nursing facility, 
     rates of rehospitalization, patients' knowledge about their 
     medical conditions and medications, and patients' 
     perspectives about the quality of their care and health care 
     providers. These evaluations may help educators at other 
     institutions determine what parts of this curriculum to try 
     at their own institutions, and to secure grant funding to 
     support such efforts. In addition, such evaluations may prove 
     helpful to policy makers as they shape the future funding 
     structure of GME.
       Like the Flexner Report a century ago, the Aliki Initiative 
     resulted from private philanthropy directed to improving 
     medical training for the public good. When doctors and 
     private citizens together view medicine and medical education 
     as a public trust, everyone benefits. It also reminds medical 
     educators that we cannot accept the status quo and need to 
     show the public what our vision for patient-centered care can 
     and must be. As Molly Cooke and her coauthors write, ``No one 
     would cheer more loudly for a change in medical education 
     than Abraham Flexner. . . . He would undoubtedly support the 
     fundamental restructuring of medical education needed today. 
     Indeed, we suspect he would find it long overdue.''
       Acknowledgment: The Aliki Initiative is funded through the 
     Johns Hopkins Center for Innovative Medicine, thanks to the 
     generosity of Mrs. Aliki Perroti.

                          ____________________